(d) Specify type of organizational structure:

1. (1) Governmental.

   1. (i) State.
   2. (ii) Municipal.
   3. (iii) Public corporation or authority.
   4. (iv) Other (Specify).

2. (2) Voluntary.

   1. (i) Type A.
   2. (ii) Type B.
   3. (iii) Type C.
   4. (iv) Type D.
   5. (v) Religious corporation.
   6. (vi) Article IX-C corporation.
   7. (vii) Other (Specify).

3. (3) Proprietary.

   1. (i) Individual.
   2. (ii) Partnership.
   3. (iii) Corporate.

(e) Compensation:

1. (1) Amounts paid to officers, directors and trustees.
2. (2) Five highest paid employees earning in excess of $30,000 per year.
3. (3) If applicable, hospital must provide a copy of Schedule A of IRS Form 990.

(f) A listing of physicians and/or professional corporations providing medical services and receiving money payments from the hospital:

1. (1) Basic selection criteria:

   1. (i) Governing authority approval.
   2. (ii) Payments exceed 10 percent of the functional cost center's direct cost.

2. (2) Information to be provided:

   1. (i) Name of physician or professional corporation.
   2. (ii) Number of individuals providing service to the hospital.
   3. (iii) Amount of payments made by the hospital.

3. (3) Applicable functional cost centers:

   1. (i) Account 6710—Emergency Services.
   2. (ii) Account 7080—Anesthesiology.
   3. (iii) Account 7210—Laboratory Services—Clinical.
   4. (iv) Account 7230—Laboratory Services—Pathological.
   5. (v) Account 7250—Whole Blood and Packed Red Cells.
   6. (vi) Account 7320—Radiology—Diagnostic.
   7. (vii) Account 7340—C.T. Scanner.
   8. (viii) Account 7360—Radiology—Therapeutic.
   9. (ix) Account 7380—Nuclear Medicine.
   10. (x) Account 7420—Respiratory Therapy.
   11. (xi) Account 7510—Physical Therapy.

(g) Medical Staff statistics for the reporting period:

1. (1) Number of physicians with admitting privileges.
2. (2) Number of physicians who admitted 20 or more inpatients.
3. (3) Number of physicians who admitted 100 or more inpatients.

(h) Emergency Room physician contract service (account 6710):

1. (1) Does the hospital contract for private physician coverage?
2. (2) If so, is there a guaranteed minimum payment?
3. (3) If so, what is the amount of this payment for this reporting period?
4. (4) If so, what is the amount of billed charges for this reporting period?
5. (5) Do the contract physicians cover on a 24-hour, 7-day-a-week basis?
6. (6) If not, to what extent is coverage contracted for?
7. (7) If contract exists, a copy must be submitted.

(i) Residency training program (accounts 8240 and 8250):

1. (1) Approvals:

   1. (i) American Medical Association; and/or
   2. (ii) American Dental Association.

2. (2) Data requirements for each specialty for which training is provided:

   1. (i) Length of program.
   2. (ii) Number of residencies offered (excluding first-year trainees).
   3. (iii) Number completing program last year.
   4. (iv) Number of American and/or Canadian graduates receiving training this year.
   5. (v) Number of foreign graduates receiving training this year.
   6. (vi) Number receiving training through an affiliated program.

(j) Student RN training program (account 8220):

1. (1) Length of course.
2. (2) Number of students.

3. (3) Tuition charges:

   1. (i) First year $____.
   2. (ii) Second year $____.
   3. (iii) Third year $____.